INDICATIONS FOR THROMBO-PROPHYLAXIS AND WHEN TO … · • High risk cardiovascular condition – Continue with aspirin around time of surgery, rather than stopping 7 – 10 days

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INDICATIONS FOR THROMBO-PROPHYLAXIS AND WHEN TO STOP ANTICOAGULATION

BEFORE ELECTIVE SURGERY

N.E. Pearce


INTRODUCTION• Preventable death• Cause of morbidity and mortality• Risk factors• Pulmonary embolism (PE) is the commonest preventable

cause of death • Preventing venous thromboembolism (VTE) • Various thromboprophylactic modalities


References


REFERENCES:• Jacobson BF, Louw S, Mer M, et al. Venous thromboembolism – prophylactic

and therapeutic practice guideline. S Afr Med J 2009; 99: 467-473.

• Venous thromboembolism: reducing the risk for patients in hospital Clinical guideline Published: 27 January 2010 nice.org.uk/guidance/cg92

• Venous Thromboembolism Prophylaxis– Adult– Inpatient/Ambulatory– Clinical Practice, Jennifer Lai, Anne Rose, PharmD

• Executive Summary : Antithrombotic, http://chestjournal.chestpubs.org/content/141/2_suppl/7S.full.html

http://chestjournal.chestpubs.org/content/141/2_suppl/7S.full.html


RISK BENEFIT


Patient information DVT prevalence %Internal medicine 10 - 20General surgery 15 - 40Major gynaecological surgery 15 - 40Major urological surgery 15 - 40Neurosurgery 15 - 40Stroke 15 - 40Hip and knee replacement surgery 40 - 60Hip fractures 40 - 60Polytrauma 40 - 80Spinal cord injury 60 - 80Critical care 10 - 80


REDUCING RISK OF VTE


PHARMACOLOGICAL– Aspirin– LMWH– LDUFH– Fondaparinux– Warfarin


ASPIRIN


LMWH


LDUFH


FONDAPARINUX


WARFARIN


MECHANICAL• Early ambulation• Intermittent pneumatic compression stockings

(IPC)• GCS• Mechanical foot compression• IVC filters



EARLY AMBULATION


IPC


GCS


MECHANICAL FOOT COMPRESSION


IVC FILTERS



LOW

HIGH

MEDIUM



1 Point 2 Points 3 Points 5 Points Age 41-60 Age 61-74 Age ≥ 75 Acute spinal cord injury

(< 1 mo)

Acute MI (<1 mo) Central venous access Established thrombophilia

Elective lower extremity arthroplasty

BMI > 25 Immobile > 72 hrs HIT Hip, pelvis, or leg fracture (< 1 mo)

CHF exacerbation (<1 mo)

Leg plaster cast or brace Hx of VTE Stroke (< 1 mo)

Hx of inflammatory bowel disease

Malignancy Family hx VTE (1 degree relative)

Procedure with local anesthesia

Surgery- arthroscopic

Swollen legs or Varicose veins Surgery > 45 mins Sepsis (< 1 mo) Serious lung dx ex. Pneumonia (<1 mo)

1 point (For Women Only) Oral contraceptives or HRT Pregnancy or postpartum (< 1 month) Hx of unexplained stillborn infant, spontaneous abortion (≥3), premature birth with toxemia or growth restricted infant


Points Risk Recommendation

0 Very Low VTE Risk Early and frequent ambulation

1-2 Low VTE Risk Mechanical Prophylaxis

3-4 Moderate VTE Risk and Low Bleed Risk

Pharmacologic Prophylaxis

> 5 High VTE Risk and Low Bleed Risk

Mechanical AND Pharmacologic Prophylaxis

> 2 High Bleed Risk Mechanical Prophylaxis


Surgical Patients Enoxaparin 40 mg SQ every 24 hours (Class I, Level B) OR Heparin 5000 units SQ every 8 to 12 hours (Class I, Level B)

Renal impairment (CrCl < 30 mL/min)* *Not on renal replacement therapy

Enoxaparin 30 mg SQ every 24 hours (Class IIa, Level B) OR Heparin 5000 units SQ every 8 to 12 hours (Class I, Level B)

Bariatric Surgery Enoxaparin 40 mg SQ every 12 hours (Class IIa, Level B)

Major Trauma Enoxaparin 30 mg SQ every 12 hours (Class IIa, Level B)

Abdominal/Pelvic Surgery for Cancer

Enoxaparin 40 mg SQ every 24 hours (Class I, Level B)



Risk Factor Points Critically Ill 4 Inflammatory Bowel Disease 4 Active Cancer* 3 Previous VTE 3 Reduced Mobility** 3 Thrombophilic Condition*** 3 Recent (< 1month) Trauma/Surgery 2 Age ≥ 70 years 1 Heart or Respiratory Failure 1 Acute Myocardial Infarction or Ischemic Stroke

1

Acute Infection or Rheumatologic Disorder

1

BMI ≥ 30 1 Ongoing Hormonal Treatment 1

Assessment Score Risk Recommendations< 4 Low VTE Risk VTE prophylaxis not needed> 4 High VTE Risk and

Low Bleed RiskPharmacologic Prophylaxis

High VTE Risk and High Bleed Risk

Mechanical Prophylaxis



Medical patients Surgical patientsActive gastroduodenal ulcer Active bleeding or previous major

bleedingBleeding in the 3 months prior to admission

Renal failure (CrCl < 30 mL/min)

Platelet count < 50 x109/L Hepatic failure (INR > 1.5 without anticoagulants)ThrombocytopeniaAcute strokeUncontrolled systemic hypertensionConcomitant use of anticoagulants, antiplatelets or thrombolytics



WARFARIN THERAPY• Stop Warfarin 5/7 pre-op• Restart Warfarin 12-24 hrs post-op, if there is adequate haemostasis• Mechanical valves/AF

– High risk for VTE• Bridging anticoagulation

– Low risk for VTE• No bridging anticoagulation

– Intermediate risk• Mx on case by case basis


MINOR DENTAL PROCEDURES

o Continue with Warfarin with coadministration of prohaemostatic agent OR

o Stop Warfarin 2-3 days pre-op


DERMATOLOGICAL PROCEDURES– Continue with Warfarin and optimize local haemostasis rather than

interrupting treatment


UFH/LMWH• Bridging anticoagulation

– UFH • Stop 4-6 hrs pre-op

– LMWH • 24 hrs pre-op (therapeutic dose)• Resume 12-24 hrs post-op• High risk of post-op bleeding• Resume 48-72 hrs post-op


ASPIRIN THERAPY• High risk cardiovascular condition

– Continue with aspirin around time of surgery, rather than stopping 7 –10 days pre-op

• Low risk cardiovascular condition– Stop aspirin 7 – 10 days pre-op

• Requiring CABG– Continue aspirin

• Coronary artery stents (on dual antiPLT Tx)– Defer surgery for at least 6/52 – bare metal stent– Defer surgery for at least 6/12 – drug-eluting stent




TIMING OF PROPHYLAXIS• Benefits of prophylactic anticoagulation pre-operatively.• Prophylaxis postoperatively is adequate• Adjustment of the dose in patients with renal failure is mandatory • The first dose of fondaparinux should always be given a minimum of

6 - 8 hours postoperatively• The new oral anticoagulants (NOACs) must only be given

postoperatively, dabigatran 4 hours and rivaroxaban 6 hours after surgery.

• Neuroaxial anaesthesia initiated a minimum of 12 hours postoperatively.



ACUTE KIDNEY INJURY (AKI) OR CHRONIC KIDNEY DISEASE (CKD)

• UFH is the preferred agent for patients who are on renal replacement therapy

• Enoxaparin 30 mg every 24 hours may be considered• Consider monitoring anti-Xa level after 7-10 doses to evaluate for

accumulation • Goal anti-Xa 0.2-0.4 units/mL


EXTREME OBESITY• Optimal thromboprophylaxis has not been established • Preferred method for VTE prophylaxis is with LMWH • Enoxaparin 40 mg every 12 hours • Routine anti-Xa monitoring is not recommended • Consider monitoring anti-Xa level after 7-10 doses to evaluate for

accumulation (goal 0.2 – 0.4 units/mL) • Prophylactic UFH has not been adequately studied in morbidly obese

patients• May consider heparin 7,500 units every 8 hours



BARIATRIC SURGERY• Patients with high VTE risk, low bleed risk

and BMI > 55 kg/m2 • Enoxaparin 40 mg SQ every 12 hours for

10 days


ABDOMINAL OR PELVIC SURGERY FOR CANCER

• Patients with a cancer diagnosis who received a traditional laparotomy or vulvectomy and is either > 60 years or < 60 years old with a history of VTE

• Enoxaparin 40 mg SQ every 24 hours for 28 days• If patient refuses 28 days of prophylactic therapy then

enoxaparin or UFH may be considered for 14 days


ORTHOPAEDIC SURGERY FOR VTE PROPHYLAXIS • Total hip arthroplasty: 10-14 days • Total knee arthroplasty: 10-14 days• Hip fracture surgery: 10-14 days • For major orthopaedic surgery 35 days


PATIENTS WITH MAJOR TRAUMA: TRAUMATIC BRAIN INJURY, ACUTE SPINAL INJURY, AND TRAUMATIC SPINE INJURY• For major trauma patients, it is suggested you use

LDUH, LMWH, or mechanical prophylaxis, preferably with IPC, over no prophylaxis; if no contraindication exists.



SPINAL AND EPIDURAL ANAESTHESIA• Neurological monitoring is mandatory • Extreme caution should be exercised in patients on other haemostatically

active agents


SPINAL AND EPIDURAL ANAESTHESIA• LMWH:

– Catheter should not be placed or removed within 12 hours following a– LMWH should not be commenced less than 2 hours after insertion or removal– LMWH should be delayed for at least 24 hours if there is blood in the needle or

neuroaxial catheter during needle insertion.


SPINAL AND EPIDURAL ANAESTHESIA• Fondaparinux:

– Catheter removal should not take place earlier than 36 hours after cessation of fondaparinux.


SPINAL AND EPIDURAL ANAESTHESIA• NOACs, rivaroxaban and dabigatran:

– Epidural catheter removal: 22 - 26 hours after last administration of a NOAC.



PATIENT INFORMATION AND PLANNING FOR DISCHARGE• Offer patients and/or their families or carers verbal and

written information• The risks and possible consequences of VTE • The importance of VTE prophylaxis • Its possible side effects the correct use of VTE

prophylaxis (for example, anti-embolism stockings, foot impulse or intermittent pneumatic compression devices)

• How patients can reduce their risk of VTE


INFORMATION

1. Indication for therapy2. Effect in preventing clotting3. Control of therapy4. Duration of therapy5. Possible complications6. Interaction with other therapies7. Toxicity keep out of reach of children.



CONCLUSION• All decisions must include a risk benefit

evaluation. • No ‘one solution fits all’ is acceptable. • Methods, timing etc. for every patient must be

clearly understood.



REFRENCES:• Jacobson BF, Louw S, Mer M, et al. Venous thromboembolism – prophylactic

and therapeutic practice guideline. S Afr Med J 2009; 99: 467-473.•• Venous thromboembolism: reducing the risk for patients in hospital Clinical

guideline Published: 27 January 2010 nice.org.uk/guidance/cg92•• Venous Thromboembolism Prophylaxis– Adult– Inpatient/Ambulatory– Clinical

Practice, Jennifer Lai, Anne Rose, PharmD•• Executive Summary : Antithrombotic,




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INDICATIONS FOR THROMBO-PROPHYLAXIS AND WHEN TO … · • High risk cardiovascular condition – Continue with aspirin around time of surgery, rather than stopping 7 – 10 days